Blue Care Group Outline of Benefits

Outline of Benefits
Benefit Period Calendar Year
Calendar Year No Limit
Covered Services
Network Provider Non-Network Provider
Calendar Year Out-of-Pocket Options Individual: $1,000; $5,000; $6,350
Family: 2 times the Individual Amount
No limit for Out-of-Network Providers
Benefits/Co-insurance Options 90%
80%
70%
50%
Healthy You! Wellness Benefit
Services based on age and gender

For a complete listing of the Healthy You! screening guidelines, visit the Healthy You! page.
100% with no co-pay, co-insurance or deductible. Not covered
Deductible Options
Calendar Year Medical Deductible Options Individual:$250; $500; $750; $1,000;
$1,250; $1,500; $1,750; $1,900;

Family: 2 times the Individual Amount
Individual:$500; $1,000; $1,500; $2,000;
$2,500; $3,000; $3,500; $3,800

Family: 2 times the Individual Amount
Calendar Year Prescription Drug Deductible Options
(Varies, based on medical deductible)
$0; $100; $250;
Prescription Drugs
Benefits are provided for Prescription Drugs included in the Prescription Drug Formulary and Maintenance Formulary.

If the Member chooses a Category Four Prescription Drug that has a low-cost alternative, the benefit will pay only the cost of the low-cost alternative. The Member will be responsible for the remaining balance after the benefit is paid.
be RxSmart. it's your choice.sm Community PLUS Pharmacy Non-Community PLUS Pharmacy
Category 1-Generally includes low-cost generic and some brand name drugs. $10 or $15 Not Covered
Category 2-Generally includes higher-cost generic and many brand-name drugs. $25 or $35 Not Covered
Category 3-Generally includes some brand-name drugs and some generic drugs. These drugs may have generic or brand-name alternatives in Category 1 or 2. $50 or $75 Not Covered
Category 4-Generally includes high cost generic drugs, high cost technology drugs and specialty drugs. $100 Not Covered
Maintenance Medications (90-day supply)

100% after 2.5 times co-pay for generic medications.
100% after 3 times co-pay for brand medications
Must use Community PLUS Maintenance Pharmacies

Not Covered
Generic First / Generic Only Some brand name medication will not be covered if there is a generic equivalent. Some brand name medication will be covered only after a similar generic medication is prescribed first. Not Covered
Disease Specific Drugs
  Network Provider Non-Network Provider
Drugs must be provided by a Network Disease Specific Pharmacy or a Member’s Non-Pharmacy Network Provider, have been Prior Authorized by the Company, and listed in the Disease Specific Drug Formulary
100% after 10% of the Allowable Charge or Varying Co-payment whichever is less, up to a $200 co-pay with a minimum $100 co-pay.
Not Covered
Covered Services
Network Provider Non-Network Provider
Physician (MD or DO) Office Visit Co-pay Options
Applies to the office visit only.
Primary Care Physician: $15, $20, $25, $30, $40, $50
Specialist: $20, $25, $30, $40, $50
50%
Deductible Applies
Physician Office Services (MD or DO)
Office Visits Only
- Other than Preventive/Wellness.
Other Office Services - Other than Preventive/Wellness. Includes injections, X-ray/lab, surgery, etc.
100% after Co-pay
Deductible Waived

Benefits/Co-insurance
Deductible Waived
Benefits/Co-insurance
Deductible Applies
Newborn Well Baby Care - Exams and routine hospital nursery care of a well newborn. Benefits/Co-insurance
Deductible Applies
Benefits/Co-insurance
Deductible Applies
Hospital Inpatient Services Benefits/Co-insurance
Deductible Applies
Benefits/Co-insurance Deductible Applies
Emergency Room Services -
Non-emergent services are subject to additional co-pay
Benefits/Co-insurance
Deductible Applies
Benefits/Co-insurance
Deductible Applies
Ambulatory Surgical Facility Services
Benefits/Co-insurance
Deductible Applies
Benefits/Co-insurance
Deductible Applies

Allied Primary Care Health Professional - Nurse Practitioner / Nurse Midwife / Physician Assistants
Office Visits - Co-pay does not apply to any Other Services rendered in the office.
Other Office Services - Deductible does not apply to services rendered by a Network Provider.

100% after Co-pay

 

Benefits/Co-insurance
Deductible Waived

Benefits/Co-insurance
Deductible Applies

Allied Specialists - Optometrists, Chiropractors, Podiatrists
Limited to 20 visits per calendar year for physical medicine services from chiropractors, physical therapists and occupational therapists.
Office Visits - Co-pay does not apply to any other services rendered in the office.
Other Office Services - Deductible does not apply to services rendered by a Network Provider.

100% after Co-pay

Benefits/Co-insurance
Deductible Waived

Benefits/Co-insurance
Deductible Applies
Approved Allied Services
DME, Ambulance, Prosthetics/Orthotics, etc.
Benefits/Co-insurance
Deductible Applies
Benefits/Co-insurance
Deductible Applies
Diabetes Treatment - Must have a diagnosis of diabetes.
Equipment, supplies for monitoring of blood glucose and insulin administration - Home glucose monitors limited to 1 every 2 calendar years. Prescription Drug Benefits will be provided for diabetic supplies (blood testing, urine testing, and lancets).
Self-Management Training - one visit per calendar year.
Dilated Eye Exam - one exam per calendar year.
Preventive Routine Foot Care - one visit per calendar year.
Benefits/Co-insurance
Deductible Applies
Benefits/Co-insurance
Deductible Applies
Approved Therapy Services
Chemotherapy, Radiation, etc.
Benefits/Co-insurance
Deductible Applies
Not Covered
TMJ
Co-pays are applicable to Network Physician Office Visits
Benefits/Co-insurance
Deductible Applies
Not Covered
Physical Medicine - Limited to 20 visits per calendar year; combined with Allied Specialist visits. Benefits/Co-insurance
Deductible Applies
Not Covered
Organ Transplant - No benefits provided without prior approval and case management.
Donor Benefits

Benefits/Co-insurance
Deductible Applies

Not Covered
Hospice Care
Limited to 6 months per lifetime, subject to care management
Benefits/Co-insurance
Deductible Applies
Not Covered
Nervous / Mental Care*

Hospital Inpatient Care

Benefits/Co-insurance
Deductible Applies
Benefits/Co-insurance
Deductible Applies
Partial Hospitalization Benefits/Co-insurance
Deductible Applies
 Benefits/Co-insurance
Deductible Applies
Hospital Outpatient Visits Benefits/Co-insurance
Deductible Applies
 50%
Deductible Applies
Other Physician Outpatient Services
Benefits/Co-insurance
Deductible Applies
 50%
Deductible Applies
Physician Office Visits 100% after Co-pay  50%
Deductible Applies
Other Services Rendered in Physician's Office Benefits/Co-insurance
Deductible Waived
 50%
Deductible Applies
Pediatric Vision & Dental Pediatric dental Benefits are available for members up to age 19. Benefits include preventive and diagnostic dental care as well as certain surgical dental services. This Benefit will pay primary to any other dental coverage provided by the Company.

Prior Authorization must be obtained by a Network Provider for non-emergent elective services provided outside the State of Mississippi unless the member resides out-of-state.

This summary of the Blue Care Group Benefit Plan is designed for the purpose of presenting general information about the Benefit Plan and is not intended as a guarantee of benefits. It is not a Summary Plan Description and in the event of a conflict between this document and the actual Benefit Plan, the terms of the Benefit Plan will prevail.